What is already known about this topic? Smoking prevalence among American Indians in the Upper Midwest is the highest among all American Indians, and considerably higher than the smoking prevalence of the general population. Little is known about nonceremonial tobacco use among urban American Indians, and surveillance estimates are limited by small sample size, culturally inappropriate data collection methods, lack of attention to ceremonial tobacco use, and exclusion of American Indians who indicate more than one race. What is added by this report? Among American Indians surveyed in Hennepin and Ramsey counties, Minnesota, 59% were current smokers, and 19% were former smokers. Smoking was most common among persons aged 25–44 years (72%). Reports of secondhand smoke exposure were high, including 42% who reported exposure in the workplace. What are the implications for public health practice? Cigarette smoking is a substantial public health problem in this subpopulation. Culturally specific adaptations of strategies that have produced U.S. population-wide declines are needed. These could include engaging traditional healers and respected elders, fostering respect for traditional ceremonial use of tobacco as a reason for not smoking recreationally, and addressing tobacco addiction in the context of social determinants of health specific to American Indians.